Twiddler's syndrome and dirty machines (some work stuff)

I took these two photos in theatre. I've decided not to write all the gory details about the case here, but I will tell you a little:

A poor old dementia patient presented to emergency with a pulse rate of about 27. I tested his pacemaker to see if getting it to yell louder at his heart would fix the problem. It did: He had a lovely pulse until the test finished and then his heart decided it wouldn't beat at all on its own. After a really frightening amount of absent pulse (during which time MY heart rate was a little unhealthy too) I gave up on traditional (slow) programming and hit the emergency pace button. Then after I'd calmed down and he'd had a respectable amount of recovery time I set about doing the tests again in a safer mode, contacted the cardiologist to recommend a new pacing lead, and cranked his device to the safest appropriate setting. The placid semi-conscious patient suddenly became quite a handful. He was much easier to manage when his brain wasn't getting enough blood.

His later repeated test results were variable, but we were eventually able to reproduce his initial problem and he ended up in theatre. It took a couple of goes to get a satisfactory result. We ended up with some beautiful ECG images.

right bundle branch block due to lead in coronary sinus

Left bundle branch block

We pace the left heart first (right bundle branch block) if the pacing wire enters a vein(the coronary sinus) and wraps around the outside of the left ventricle. If it is directly in the right ventricle we get a left bundle branch block pattern on the ECG.

Would you believe that this poor fella came back AGAIN after a few weeks with a pulse rate of 37? It turned out that he had been "twiddling", or in other words, he had been turning the small flat metal pacemaker over and over under his skin, twisting the leads into tight coils that shortened their overall length and basically ripped the lead tips right out of his heart. The surgeons went back in and repositioned the device deeper (under his muscle). Hopefully that will be the end of it.

My last image is a picture of how I found the ultrasound imaging probe one Friday morning. Ugh. It  turned out that the previous sonographer had rushed off to attend a meeting. I wish she had left a note on it to say "THIS MACHINE IS DIRTY, I WILL CLEAN IT IN 30 MINS" because then I wouldn't have felt quite so outraged.  Fortunately I noticed before bringing a patient into the room, and our fabulous new aid Sharon helped me scrub the entire machine. We finished just as the culprit returned, and I must say that it was a relief to hear her explanation.